Per-operative frozen section examination of pelvic nodes is unnecessary for the majority of clinically localized prostate cancers in the prostate-specific antigen era

One step nucleic acid amplification (OSNA) for detection of lymph node metastasis during robotic radical prostatectomy for prostate cancer: A pilot study

Introduction: The OSNA technique is based on reverse transcription loop-mediated DNA amplification for the detection of cytokeratin 19 (CK19) messen-ger RNA (mRNA). The purpose of our paper, which represents the first study in the literature, is to test the accuracy of this method in the detection of lymph node metastases in patients undergoing robotic radical prostatectomy with lymph node dis-section. Methods: Our cohort consisted of patients that have undergone robotic radical prostatectomy with extended lymph node dissec-tion. Lymph nodes were evaluated with imprint technique and then with frozen section examination. The remaining tissue was evaluated by OSNA method. Lymph nodes were defined as ‘neg-ative’ or ‘positive’ according to mRNA copy number. Results: 7 patients and 25 lymph nodes were included in our cohort. Two patients were found negative with all pathology methods. In one patient the standard stains revealed a suspi-cious outcome but it was positive for micrometastasis with OSNA. In another patient the outcome was positive for standard stains and negative for OSNA. Finally, 2 patients were found positive for OSNA and negative for imprint methods. Conclusions: One Step Nucleic Acid Amplification (OSNA) method using CK19 seems to fail in detection of lymph node metastases in prostate cancer patients undergoing radical prostatectomy and lymph node dissection.

The role of lymph node dissection in the management of prostate cancer

Lymph node dissection is a standard procedure for treatment of several cancers, but its role in prostate cancer (PCa) as an adjunct of radical prostatectomy is still debated and controversial. Pelvic lymph node dissection (PLND) is currently the most reliable means of diagnosis of lymph node metastases. A uniform PLND surgical template cannot be determined, but recent evidence shows that extended PLND provides more lymph nodes, increases the accuracy of detection of lymph node metastases, and affects decision making with regard to adjuvant therapy. Several nomograms have been developed to predict those who may need more extensive PLND, while sparing the rest. Importantly, no prospective data indicate that extension of PLND improves cancer control or benefits survival. A well designed prospective randomized study is needed to resolve these issues. We present a comprehensive literature review and critical discussion of the diagnostic and therapeutic role of PLND in PCa.

Lymph node dissection during robot-assisted radical prostatectomy: where do we stand?

Since the initial report of robot-assisted laparoscopic prostatectomy (RALP) in 2001, the technique has gained rapid acceptance and utilization. When compared with more traditional forms of surgical intervention, there is still much debate with respect to cost, and impact on potency and continence. Less often is the focus on oncologic outcomes. Pelvic lymph node dissection (PLND) at the time of prostatectomy is an important part of the surgical intervention for prostate cancer and is currently underreported during robotic procedures. Herein, we review the current controversies on the value and extent of PLND and the status of emerging data regarding robot-assisted PLND.

MR imaging of pelvic lymph nodes

The occurrence of metastases to pelvic lymph nodes profoundly affects the prognosis of pelvic malignancies, making accurate staging crucial for selecting appropriate treatment. Modalities for the detection of metastatic lymph nodes are lymph node dissection, lymphangiography, and non-invasive techniques such as computed tomography (CT) and magnetic resonance imaging (MRI); the role of these techniques will be reviewed. Although this review will focus on prostate cancer, the statements may be generalised for other malignancies, as the metastases in pelvic lymph nodes have a similar pattern for other tumors.

Is it necessary to do staging pelvic lymph node dissection for T1c prostate cancer?

The necessity of pelvic lymph node dissection has been questioned in recent years as a result of improved pre-treatment staging based on clinical and pathologic factors. Accurate evaluation of nodal status allows rational selection of therapy and improved outcomes. Nevertheless, lymph node dissection may play a role even in patients with low stage disease (clinical T1c) despite an overall low risk for metastases. Herein we discuss recent advances in the evaluation of lymph nodes in stage T1c prostate cancer with respect to accurate prediction, radiologic imaging, molecular characterization, and operative considerations.